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I I APPLICATION FOR lIOUID WASTE PERMIT SAN'JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O.BOX 388,446 N.SAN JOAOUIN ST.,STOCKTON,CA 96201-0388 12091468-3420 NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED icampIELA in TTiplianl AFPUCATION IS HEREBY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION 13 MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE.CHCCAPTFR 9-1110.3 APO THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION. 1 4 L JOB ADDRESS/OR APNR ! •�.S./ `�./� P 1 � CRY -rte C'7 LOT SIZE ,Y.� OWNER'S NAME Q CONTRACTOR S.+eve- `J� �11�1"��+� ADDRESS SUB CONTRACTOR V T l 1 -t_ 1�/I(�1 ADDRESS _P'.) f71X L C�;) Uci PHO E S - 2 2_ TYPE OF SEPTIC WORN: WIN INSTALLATION❑ REPuwADDITION DEBTALKMON❑ (NO SEPTIC SYSTEM PERMITTED IF PUBLIC SEWER IS AVNLMS WITHIN 200 FEET OF BUILDING.y PERT TOTNI 1 1 NOW MANY AppSoidon INSTALLATION WILL SERVE: RESIDENCE P' COMMERCIAL❑ OTHER❑ NUMBER OF LIVING UMTS: I ...It 0.F SEORDOMS: NUMBEL OF EMPLOYOX; CHARACTER OF SOIL TO A DEPTH OF 3 FEET;cj-iob,�- _PTTlSUMP SOIL CHARACTER: WATER TABLE DEPTH^�7� SEPTIC TANKJORELSE TRAP 63'rmi:l FG t'}L CAPACITY 1 1 L-� NO.COMPA7RMEHTB �+ PKO TWATMEYIT PLANT❑ DISTANCE TO NEAREST: WELLFOUNDATION PROPERTY UNE LIFT STATION❑ SIZE TYPE OF PUMP SAND OIL SEPARATOR(ENCLOSED SYSTEM) U• LEACNNO UNE ❑ NO.N LENGTH Of LNEB DISTANCE TO NEAREST:WELLFOUNDATION PFODPERTY LINE FILTEI BED ❑YNDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPERTY UNE Ma UNOED ❑WIOTII LENGTH DEPTH DISTANCE TO NEAREST:WILL.-FOUNDATION PROPERTY LINE O SEEPAGE RYTS ❑DEPTH SIZE NUMBER DISTANCE TO NEAREST:WELL--FOUNDATION PROPERTY UNE L SUMPS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL FOUNDATION PROPENTY UNE DISPOSAL PONOS ❑WIDTH LENGTH DEPTH DISTANCE TO NEAREST:WELL__FOUNDATION PROPETRY UNE L` I HERESY CERTIFY THAT 1 HAVE PREPARED THIS APPUICATON AND THAT THE WORK VALL/R DONE IN ACCORDANC£WITH SAN JOAOUIN COUNTY ORDINANCES AND STATE LAWS.AND RULES r+- AND REGULATIONSOFTHE SAN JOAQUIN COUNTY.HOMEOWNER OR LICENSEDAGENT•S SIGNATURE CERTIFIES THE FOLLOWING;'I CERTIFY THAT IN THE PERFORMANCE OF THEWOAK FOR WlNCH O THIS PERMIT IS ISSUED,I SHALLNOT EMPLOY ANY PERSON IN SUCH A MANNER.AS TO BECOME SUBJECT TO WOFKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUS-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING;'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,/SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' NIIA' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIREDINSPECTIONS. COMPLETE DRAWING BELOW. (7� SIGNED X `A�/` — ja&t' TITLE: DATE: J ROT PLAN[DRAW TO SCALEI SCAL-r. To — I.HAMEs OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY, a.LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPE]",WITH DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. S. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, S.LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY Fr.ON INCLUDING COVERED AREAS SUCH AB PATIOS.DRIVEWAYS,AND WALKS. THE PROPERTY OR ADJOINING PROPERTY. h �+ i ;2 7 i , w tr 41 .j J iviA11 FOR O@MRMENT USE ONLY APPLICATION ACCEPTED BY TAN(.RT OR SUMP INSKCTION SY UATEE ! I FINAL INSPECTION BY w Y 'w DATE 3 !I O !� p ADDITIONAL COMMENTS: v ACCOUNTING ON Y:/„ AIDE FACT PF CODE FEF INFO AMOUNT REMITTED HECK;JCASH RECEIVED BY DATE SR J PERMIT.—ER INVOICE i I I SIzt�Dc�Fs�l.